Basic Information
| Provider Information | |||||||||
| NPI: | 1134732761 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAFFNEY | ||||||||
| FirstName: | TIMOTHY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063295615 | ||||||||
| FaxNumber: | 4063295606 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W BROADWAY ST STE 320 | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063295615 | ||||||||
| FaxNumber: | 4063295606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2020 | ||||||||
| LastUpdateDate: | 10/28/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 09/14/2021 | ||||||||
| NPIReactivationDate: | 10/05/2021 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | MED-PAC-LIC-102492 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.